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# HEALTH BENEFITS REGISTRATION FORMStandard Form No. 7109CHAPTER 1-53 PM.GSA REG 5000(Read Instructions on back of last page)EMPLOYEES HEALTH BENEFITS ACT OF 1959## PART AALL WHOREGISTERMUST FILLIN THISPARTKPERAN Thomas J.6 29 301. ARE YOU MARRIED?   YES [X]   NO []4. YOUR MAILING ADDRESS:   (STREET AND NUMBER)   (CITY AND ZONE NUMBER)   (STATE)5. SEX   MALE [X]   FEMALE []6. Are you covered by, or is any family member listed below cov- Place an "X" in proper box to show your annual basic salary:   ered by or enrolling in: a plan under the Federal Employees   Health Benefits Act of 1959 (through the enrollment of another   UNDER $4,000 [] $6,000 TO $9,999 [X]   United States or District of Columbia Government employee or   $4,000 TO $5,999 [] $10,000 OR OVER []   annuitant)?   YES [] NO [X]## PART BFILL IN THISPART IF YOUWISH TO EN-ROLL IN AHEALTH BENEFITSPLAN1. I elect to enroll in a health benefits plan as shown below. I authorize deductions to be made from my salary, compensation, or annuity   to cover my share of the cost of the enrollment. (Copy the information requested below from inside cover of brochure of the plan you select.)NAME OF PLANAssociation Benefit Plan High 4 2 22. In space below list all eligible family members without exception: List your wife or husband first; then your unmarried children under   age 19, including legally adopted children, and stepchildren and illegitimate children who live with you in a regular parent-child relation-   ship. Include also any unmarried child over 19 who became disabled before age 19 and who, because of the disability, is incapable   of self-support. (Attach a doctor's certificate for a disabled child age 19 or over.)Wife orHusbandNAMES OF FAMILY MEMBERSDATE OF BIRTH(Month, Day, Year)Margaret J.12-20-34 [1]Mary Margaret10-6-57 [2]Kathleen Ann9-16-58 [3]Thomas J., Jr.5-19-60 [4]3. If you are a female (employee or annuitant) - does the family listed above include a husband who is incapable of self   support by reason of mental or physical disability which can be expected to continue for more than one year? (If answer   is "Yes," attach a doctor's certificate.)   YES []   NO [X]## PART CFILL IN THISPART IF YOUWISH NOT TOENROLL OR IFYOU WISH TOCANCEL YOURENROLLMENT.PLACE AN "X" IN ITEM 1 OR ITEM 2, WHICHEVER APPLIES AND ANSWER ITEM 3:1. I elect not to enroll in any plan   under the Health Benefits Act.3. The reason for my election is (Place an "X" in proper box):   (a) I am covered by a plan under the Health Benefits Act through the enroll   ment of my husband, wife, or parent.2. I elect to cancel my present enroll   ment under the Health Benefits Act.   (b) I am covered by a health benefits plan which is not under the Health   Benefits Act.   (c) Any other reason.## PART DFILL IN THISPART IF YOUWISH TOCHANGE YOURENROLLMENT1. I elect to change my enrollment as shown by the enrollment number and other information in Item 2.1. Enrollee's name number of present plan.2. Number of event which permits change.## PART EALL WHOREGISTERMUST FILLIN THISPART.[signature] 13 May 1960(Employee's signature and date)WARNING: - Any intentional false statement inthis registration or willful misrepresentation issubject to a violation of the law punishable by afine of not more than $10,000 or imprisonmentof not more than 5 years or both. (18 U.S.C. 1001.)## PART FTO BE:COMPLETEDBY AGENCY.1. Date received in employing officeREMARKSTotal emp'ees in this unit8. B. GOVERNTY 12612U. S. GOVERNENT PRINTING OFFICE: 109